Securities Division Complaint Form
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3Indiana Secretary of State
Securities Division Complaint Form
Online version available at:
The Indiana Securities Division can investigate possible violations of these statutes:
Indiana Securities Act (IC 23-2-1)
Indiana Loan Broker Act (IC 23-2-5)
Indiana Franchise Act (IC 23-2-2.5)
Indiana Collection Agency Act (IC 25-11)
Indiana Takeover Offers Act (IC 23-2-3.1)
I. Please select the subject matter that you feel best describes your complaint:
Securities/investments
Loan Broker
Franchise
Collection Agency
Takeover Offers
II. Please supply the following information about yourself:
Name:
__________________________________________________________________
Date of Birth: ____/____/____
Address: __________________________________________________________
Street
City, State
Zip Code
Email Address______________________________________________________
Home Phone #: (____) ____-______
Cell Phone #: (____) ____-______
III. Please supply the following information about the person(s) and entities who you
believe may have violated Indiana law:
Company name:
______________________________________________________________________
Address:______________________________________________________________
Phone number: ________________________________________________________
Website: ______________________________________________________________
Individual(s) involved:
1) ____________________________________________________________________
Address:______________________________________________________________
Phone number:_________________________________________________________
2) ____________________________________________________________________
Address:______________________________________________________________
Phone number:_________________________________________________________
Note: Please include any additional names in Section VI “Other Information”.
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Parent category: Legal